- •Foreword
- •Preface
- •Contributors
- •Reference
- •2 Evaluation of the Cosmetic Patient
- •The Eightfold Path to Patient Happiness
- •Listen to Your Patient Before Surgery (or you will surely have to listen to them after)
- •Document and Demonstrate
- •Ensure Appropriate Patient Motivation
- •Determine Realistic Surgical Goals
- •Conduct a Thorough Informed Consent
- •Create an Aesthetic Environment
- •Topical Ocular Anesthetics
- •Lidocaine
- •Bupivacaine
- •Epinephrine
- •EMLA
- •Other Topical Anesthetics
- •Bicarbonate
- •Benzyl Alcohol
- •References
- •Facial Nerve Blocks
- •Retrobulbar and Peribulbar Blocks
- •References
- •Sensory Nerve Blocks
- •Lacrimal Nerve Block
- •Frontal Nerve Block
- •Nasociliary Nerve Block
- •Infraorbital Nerve Block
- •Zygomaticofacial Nerve Block
- •Staff
- •Monitoring
- •Minimal Sedation
- •Moderate Sedation
- •Antagonists/Reversal Agents
- •References
- •Selection of Local Anesthesia
- •Selection of Oral Sedative Agent
- •Procedure
- •References
- •19 Keys to Success When Marking the Skin in Upper Blepharoplasty
- •26 Blepharoplasty Incisional Modalities: 4.0 Radiowave Surgery vs. CO2 Laser
- •Study
- •Results
- •References
- •27 Fat Preservation and Other Tips for Upper Blepharoplasty
- •28 Asian Blepharoplasty
- •29 Internal Brow Elevation with Corrugator Removal
- •41 Three-Step Technique for Lower Lid Blepharoplasty
- •Step 1: Transconjunctival Fat Removal
- •Step 3: Resuspension of the Anterior Lamella and Adjacent Malar Fat Pad to the Lateral Orbital Periosteum
- •Rationale for the Three-Step Procedure
- •Pearls
- •References
- •Divide Each Fat Pad Flush with the Orbital Rim—Nasal and Central Fat Pads
- •Divide Each Fat Pad Flush with the Orbital Rim—Lateral Fat Pad
- •Surgical Technique
- •Postoperative Care
- •Complications
- •Comments
- •References
- •54 Transconjunctival Lower Blepharoplasty with Intra-SOOF Fat Repositioning
- •Patient Selection
- •Procedure
- •Postoperative
- •Conclusion
- •References
- •56 Use of Tisseel in Lower Eyelid Blepharoplasty with Fat Repositioning
- •57 Lower Blepharoplasty with Fat Repositioning Without Sutures
- •Fat-Repositioning Procedure
- •References
- •Indications
- •Complications
- •Procedure
- •Stage 1
- •Stage 2
- •Conclusions
- •References
- •61 Treatment of Postblepharoplasty Lower Eyelid Retraction with Dermis Fat Spacer Grafting
- •Surgical Technique
- •References
- •Tumescent Technique
- •Avoiding Anesthetic Toxicity
- •Tumescent Technique
- •References
- •69 Incision Technique for Endoscopic Forehead Elevation
- •Central Incision
- •Paracentral Incisions
- •Temporal Incisions
- •Prevention of Alopecia
- •71 Endoscopic Midforehead Techniques: Improved Outcomes with Decreased Operative Time and Cost
- •Suggested Reading
- •Dissection of Central Forehead Space and Scalp
- •Dissection of Temporal Space
- •Release of Periosteum
- •77 Endosocopic Browlift with Deep Temporal Fixation Only*
- •Endoscopic Browlift with Deep Temporal Fixation Only
- •Temporal Lift
- •Surgical Technique
- •Incisions
- •Release of the Brow Depressor Muscles
- •Brow Elevation and Fixation
- •Results (Before and After Photographs)
- •Introduction
- •Surgical Technique
- •Conclusions
- •References
- •79 Scalp Fixation in Endoscopic Browlift
- •Suggested Reading
- •82 The Direct Browlift: Focus on the Tail
- •Patient Selection
- •Procedure
- •Postoperative
- •Complications
- •Conclusion
- •Introduction
- •Procedure
- •Conclusions
- •References
- •86 The Subperiosteal Mid-Face Lift Using Bioabsorbable Implants for Fixation*
- •References
- •88 Mid-Face Implants
- •105 Shaping of the Eyebrows with Botox
- •Modifying the Position of the Medial Eyebrows
- •Modifying the Position of the Lateral Eyebrows
- •Arching and Lifting the Eyebrows
- •Lowering and Flattening the Eyebrows
- •Treating Eyebrow Asymmetry
- •Pitfalls
- •Conclusion
- •References
- •109 Botox Injection to the Lacrimal Gland for the Treatment of Epiphora
- •113 Optimizing Outcome from Facial Cosmetic Injections and Promoting Realistic Expectations
- •Preparations
- •Posttreatment
- •Expectations
- •115 List of Fillers
- •Consultation
- •Anesthesia
- •Choice of Filler
- •Anatomic Guidelines
- •Technique
- •Summary
- •References
- •121 Liquid Injectable Silicone for the Upper Third of the Face
- •References
- •122 Periocular Injectables with Hyaluronic Acid and Calcium Hydroxyapatite
- •General Principles
- •Hyaluronic Acid (HA)
- •Calcium Hydroxyapatite
- •References
- •125 Pearls for Periorbital Fat Transfer
- •129 Retinoids for the Cosmetic Patient
- •Background
- •Suggested Reading
- •Patient Selection
- •Infrared vs. Pulsed Dye
- •Postoperative Care
- •Choosing a Device
- •KTP or Frequency-Doubled Nd:YAG laser (532 nm)
- •Pulsed-Dye Laser (585 nm, 595 nm)
- •Intense-Pulsed Light Device (500–1200 nm)
- •Long-Pulsed Nd:YAG laser (1064 nm)
- •Fractional Resurfacing Lasers
- •Low Intensity Sources
- •Laser and Light Sources for Skin Rejuvenation
- •Patient Evaluation
- •Surgical Planning
- •Anesthetic Techniques
- •Surgical Procedure
- •Postoperative Care
- •Background
- •Technology
- •Patient Selection
- •Treatment
- •Conclusion
- •Key Elements of Procedure
- •Patient Selection and Preparation
- •Procedure
- •Postoperative
- •Conclusion
- •References
- •145 Repair of the Torn Earlobe
- •Questions to Ask the Patient
- •Basic Principles
- •Surgical Technique for Complete Earlobe Tears
- •Surgical Repair for Partial Torn Earlobes
- •References
- •Introduction
- •Preoperative Markings
- •Technique
- •Discussion
- •Conclusion
- •Reference
- •147 SMAS Malar Fat Pad Lift with Short Scar Face Lift
- •148 Ten Tips for a Reliable and Predictable Deep Plane Facial Rhytidectomy
- •Introduction
- •Tip 1. Marking (Figure 148.1)
- •Tip 2. Skin Flap Dissection (Figure 148.2)
- •Tip 3. Marking the Zygomatic Arch (Figure 148.3)
- •Tip 4. SMAS Flap Creation (Figure 148.4)
- •Tip 5. Creating the SMAS Flap (Figure 148.5 and 148.6)
- •Tip 6. SMAS Flap Fixation (Figure 148.7)
- •Tip 7. Skin Flap Fixation (Figure 148.8)
- •Tip 8. Addressing the Earlobe (Figure 148.9)
- •Tip 9. Skin Excision Tips (Figure 148.10)
- •Tip 10. Addressing the Neck (Figure 148.11)
- •References
- •153 Adjustable Suture Technique for Levator Surgery
- •Surgical Technique
- •Reference
- •154 Tarsal Switch Levator Resection for the Treatment of Myopathic Blepharoptosis
- •Surgical Technique
- •Suggested Reading
- •156 Minimally Invasive Ptosis Repair
- •Mini-invasive Ptosis Surgery
- •Suggested Reading
- •Further Reading
- •158 Ptosis Repair by a Single-Stitch Levator Advancement
- •Reference
- •References
- •171 Medial Canthorraphy
- •Index
2
Evaluation of the Cosmetic Patient
Rona Z. Silkiss
The Eightfold Path to Patient Happiness
1. Manage the balance of power
2.Listen to the patient
3.Ensure appropriate patient motivation
4.Determine realistic surgical goals
5.Screen out the difficult patient
6.Conduct thorough informed consent
7.Avoid surgical overcorrection
8.Create an aesthetic environment
Manage the Balance of Power Between Doctor
and Patient
The relationship between the doctor and patient must be bilateral and balanced. Both the patient and surgeon must be willing to walk away from the “contract” that exists prior to surgery if signs of imbalance exist. If the balance of power lies too heavily with either the patient or the surgeon, the potential for an unhappy patient is high.
The patient must take responsibility for the initial objectives of the cosmetic surgery. In order for the surgeon to meet the patient’s expectations, they must be established by the patient to himor herself preoperatively. There must be an established metric for surgical success. If there is no defined endpoint, vague dissatisfaction or even litigation is a possible outcome.
Additionally, the decision to recommend surgery by the surgeon should not be based on whether you “can” perform surgery, but whether you “should.” Patients may be asking for reassurance and may not be ready for surgery either physically or emotionally. A patient may be reacting to the increasing pressure of early surgery perpetuated by the media. Cosmetic surgery procedures may change the patient’s perception of self and lead to an unhappy patient. A patient may already be unhappy and be sublimating this into a “surgical fix.”
6
Chapter 2 Evaluation of the Cosmetic Patient 7
In general, surgeons may advertise but should avoid “selling” their services. A patient will appreciate honesty. Surgical integrity will be rewarded many times over. What is rare and withheld is valued more highly.
Listen to Your Patient Before Surgery (or you will surely have to listen to them after)
In the course of a consultation with a patient, surgeons should specifi cally ask patients what they wish to achieve. Ask to see old photographs and remind the patient of his or her youthful configuration. Allow the patient to bring in photos of the desired or anticipated outcome.
The contrast between target and actual configuration serves as the basis of a discussion about what surgery can and cannot provide. This defines the “envelope of the possible” for the patient. Remind the patient that “perfection is not part of the equation” for results no matter how perfect the surgery or procedure.
Document and Demonstrate
Photograph the patient during the consultation and demonstrate preoperative asymmetry. Patients may not be aware of their own preoperative asymmetry. In contrast, with certainty, they will be aware of any postoperative asymmetry. Preoperative awareness and documentation may prevent the patient from ascribing their underlying preoperative asymmetry to the surgery or surgeon.
Ensure Appropriate Patient Motivation
Often patients will be motivated to seek cosmetic surgery in the event of a recent job loss, divorce, or life crisis. It is critical that the surgeon assess the patients’ motivation for surgery to decide if they are appropriate surgical candidates. Do not give the patient the opportunity to transfer his or her unhappiness to the recent surgery or surgeon. It may be useful to advise the patient to return after an interval of time when life circumstances have become more stable.
A patient’s surgical goals should be appropriate and self-generated.
The patient must be personally committed to the surgery and accept the risks of surgery and the physical alteration. Patients may be seeking reassurance from a consultant that surgery is optional at a particular point in time. Reassurance alone may be the best medicine. A patient trying to reestablish his or her own self-esteem, advised to postpone surgical intervention, may be your most grateful and happy patient.
Determine Realistic Surgical Goals
Both the surgeon and patient must be realistic. The surgeon needs a clear understanding of what a technique can optimally and usually provides. He or she needs to communicate this knowledge to patients so that their
8R.Z. Silkiss
expectations can be adjusted to an informed reality. In advising patients, do not assume that the patient shares your personal aesthetic or style. Be aware of misguided surgical goals such as:
1.An attempt by the patient to match a distant image ideal (celebrity).
2.An attempt by the patient to achieve arbitrary standards of perfection through more surgery.
3.An attempt by the patient to heal psychological pain by body alteration or wounding.
Misguided surgical goals may lead the patient “driving to imperfection.” This is a situation where the patient’s fervent desire to achieve an impossible ideal may lead to surgical outcomes that are quite the opposite of beauty.
Screen Out the Difficult Patient
Learn to recognize the warning signs of a difficult patient. This is a limited list of signs of the potentially difficult patient:
1.The patient’s chief complaint is one concerning prior surgeons.
2.The patient has already received multiple procedures and is still not satisfied.
3.The patient manifests an obsessive/compulsive approach to small or invisible suboptimalities. This may be demonstrated by overt selfintolerance or disdain or overly detailed, lengthy questions or email prior to considering the procedure.
4.The patient complains of pain or an abnormal feeling related to the cosmetic concern.
5.The patient continues to critically self-evaluate and primp in the mirror, despite your initiation of a conversation.
6.The patient appears to have an unrealistic expectation for the surgical outcome.
7.The patient refuses to “hear” the limitations of surgery and reiterates a desired outcome despite your explanation regarding the improbability or impossibility of same.
8.The patient displays an inappropriate level of familiarity or flattery, especially during the initial consultation.
9.The patient is inappropriately aggressive or hostile during the consultation or is inappropriately demanding or demeaning to the office staff.
10.The patient consultation takes an unusually lengthy period of time, making the surgeon uncomfortable with the degree of selfabsorption and detail demanded.
11.There is excessive “negotiating” about price, location, or insurance prior to surgery.
12.Repeated cancellation of the surgical date.
13.Insistence by the cosmetic patient that “their friend’s surgery was covered by insurance.”
14.The patient seeks urgent or emergent cosmetic surgery unrealistically close to an important social event such as a wedding or reunion.
Chapter 2 Evaluation of the Cosmetic Patient 9
15.Your intuition informs you that this patient is likely to be difficult, yet your ego struggles with your desire to “fix the problem” other surgeons have been unable to correct, leading to your own internal tension and turmoil.
Determine whether a potentially difficult patient is someone for whom you wish to care in the event of a problem. The consultation is the honeymoon phase. The relationship is unlikely to get easier. Ask whether the patient will later insist, should there be a suboptimal outcome in his mind, that he or she was not given alternatives, appropriate time to make an informed decision, or that the surgeon “rushed” to operate?
There are several psychiatric syndromes associated with difficult patients. The two most common are narcissism and body dysmorphic syndrome.
Narcissism is a condition in which the individual expresses an extreme need to be the center of attention. They make an inappropriate attempt to control the social environment. The etiology of narcissism is an underlying deep insecurity.
Body dysmorphic syndrome is manifest by an inaccurate, inappropriate assessment of body appearance. Patients manifest severe distress regarding their physical appearance despite numerous cosmetic procedures, irrespective of their actual appearance.
Surgery does not cure these conditions. The experiment has been done again and again and again. There is no need to repeat the experiment.
As a surgeon, you are not obligated to care for a cosmetic patient whom you view as litigious, threatening, or difficult or for whom you believe the surgery is unlikely to satisfy—independent of result.
Conduct a Thorough Informed Consent
It is critical that the operative surgeon obtain a thorough informed consent prior to surgery. In addition to the specifics of the procedure, the consent discussion must emphasize that “function trumps form” every time. The potential risks and suboptimalities of surgery should be discussed openly. The most common risk is “expectation risk,” and this should be discussed explicitly. Patients need to be reminded that that “perfection is not part of the equation” for surgery and if they will be satisfied with improvement they will likely be happy. If they are seeking perfection, they will not be happy.
During the patient consultation and consent, the patient should be educated regarding the aesthetic surgeon’s understanding of rejuvenation. In years past, more surgery, more excavation, more hollowness or tautness was considered the standard of care and sometimes even proof of getting “one’s money’s worth” in surgery. This provided patients with an unnatural, obvious, surgical alteration leading one to look “lost in time.” In contrast, the current understanding of rejuvenation emphasizes that fullness is a sign of youth and that youthful individuals are not taut, hollow, or skeletonized. Additionally, youthful individuals are not overly frozen, plump, or exaggerated in configuration.